Societal Burden of Substance Abuse

Abstract

IntroductionSubstance abuse kills hundreds of thousands of people every year, and sends hundreds of thousands more to the emergency room; for illegal drugs, black market violence adds to the toll. Billions are spent on drug treatment and on treating associated medical complications, including HIV/AIDS. Substance abuse is implicated in a large proportion of child abuse and neglect cases, and is common among youth and young adults; the 2010 National Survey of Drug Use and Health (NSDUH) estimates that of youth aged 12 to 17, 25% have used tobacco, 35% have used alcohol, and 26% have used illicit drugs in their lifetime, with 43% of 18-year-olds having used marijuana at least once (1).Common sense says the societal costs of substance abuse are large, but how large are they? Studies vary on the specific figures but all agree the costs are high. Harwood et al. produced the most frequently cited figures in the US for alcohol and drug abuse (2,3),and the Center for Disease Control and Prevention (CDC) provides a related estimate for cigarettes, which excluded cigar smoking, pipe smoking, and smokeless tobacco (4). Figure 1 shows all three adjusted to 2011 dollars, totaling over $700 billion. Throughout this paper, all dollar amounts have been inflated to 2011 dollars for ease of comparison using annual averages from the Consumer Price hidex (CPI) from the Bureau of Labor Statistics.Corresponding estimates for other countries (5,6) reveals that the US is not alone in experiencing a high societal burden of substance abuse. Among peer countries, the US has higher rates of abuse of illegal drugs but lower rates of alcohol and tobacco consumption. This article delves into the U.S. figures in detail, rather than briefly touching on estimates from multiple countries, because the focus is on understanding how to interpret the figures, not on international comparisons.The cost of illness (COI) approachMonetizing social costs is tricky, as is properly interpreting the resulting figures (7). Policy makers want a number, and analysts oblige, but the numbers come with endless footnotes and more than a little controversy. What do the figures really mean? What is included? What is excluded?Most studies take a cost-of-illness (COI) approach. COI studies estimate the net value of resources a health condition makes unavailable for other purposes. They have been conducted for conditions such as heart disease, cancer, diabetes, stroke, and Alzheimer's. Studies typically include direct and indirect costs, but often ignore intangibles such as diminished quality of life.The COI approach has become the standard in substance abuse studies, but it is not the only or even necessarily the best method available. Economists regularly employ other valuation techniques in other areas of social policy, such as crime, education, gambling and the environment.To give an example of a difference, where other frameworks value the indirect costs of illness and death in tenus of lost quality of life, COI studies use productivity losses. Not all economists agree with this valuation method, but its logic is easy to understand. When workers go on disability leave, either someone else has to do their work or society goes without the fruits of their labor. For example, if the patient were a writer, society would be made poorer by the loss of the short story that didn't get written because the writer was sick to work during that time.Embedded in this view is an assumption that the economy is functioning near full employment, so lost labor leads to lost output. Someone who thought the economy offered a fixed number of jobs, with unemployment implying there are too many workers relative to the number of jobs, wouldn't worry about this cost. One person's illness would create a job opening for someone else who would otherwise have been idle. Most COI scholars have a more optimistic view that the economy will always expand to take advantage of talent and, conversely, when sickness sidelines some of that talent, total economic output shrinks. …